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People with learning disabilities still face inequalities in access to health services. This article, which comes with a handout for a journal club discussion, sums up what nurses can do to reduce these inequalities

Upping inhaler use may not prevent asthma attacks in children

Short-term increases in inhaled steroids do not provide the benefits that are generally expected during the early stages of an attack, according to US researchers.

They found children with mild to moderate asthma did not benefit from a common practice of increasing their inhaled steroids at the first signs of an asthma exacerbation.

“We need to find better ways to identify early signs of asthma worsening”

Kristie Ross

Researchers from Case Western Reserve University found that short-term increases in inhaled steroids did not prevent attacks in children aged 5 to 11, and may even slow a child’s growth.

The study, which involved 254 children and 17 sites, was published in the New England Journal of Medicine. For one year, they measured benefits of increasing inhaled steroid doses by five times – or quintupling – during the earliest signs of an asthma attack.

They noted that this period was known as the “yellow zone”, when wheezing, coughing, and shortness of breath first appear. All the children in the study used low dose controller inhalers – “two puffs twice daily” – for a standard maintenance dose of inhaled steroid medication.

When parents noticed their child had yellow zone symptoms, the researchers instructed them to use a different inhaler for seven days. Half of the inhalers were the same low dose, and the other half contained five times the maintenance dose.

Across 395 yellow zone episodes, the researchers did not find any significant difference in the number of asthma attacks that ultimately required systemic steroids. Despite a 16% increase in exposure to inhaled steroids, children in the high-dose group did not experience fewer attacks.

The rate of severe exacerbations treated with systemic glucocorticoids was 0.48 exacerbations per year in the high-dose group and 0.37 exacerbations per year in the low-dose group.

“Quintupling the dose at the early signs of loss of asthma control did not reduce the rate of severe asthma exacerbations”

Study authors

However, the researchers did find children in the high-dose group had slower growth rates, averaging 0.23cm per year less than children who maintained the low-dose regimen.

Children with over two yellow zone episodes in a year, and children aged 5-7 were most affected, they said. But the researchers cautioned that the study did not include children with severe asthma who may be more prone to exacerbations, or children with uncontrolled asthma.

Study author Dr Kristie Ross, assistant professor of paediatrics at Case Western, said: “Increasing the dose of inhaled steroids at early signs of asthma worsening along with using quick relief medicines to relieve symptoms is a common practice.

“Our study shows that this is no more effective at preventing progression to more serious asthma exacerbations than the use of quick relief medicines alone, such as albuterol inhalers,” she said.

“We need to find better ways to identify early signs of asthma worsening that are likely to lead to more serious asthma exacerbations,” added Dr Ross, who is also clinical director of paediatric pulmonology, allergy and immunology at University Hospitals Rainbow Babies and Children’s Hospital in Cleveland.

“We will be starting a study this summer on a way to do that using technology that collects information about the child and the environment with less burden on the family, that may help us better predict asthma flares,” she noted.

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